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Inspection on 06/09/06 for Sceats Memorial Home

Also see our care home review for Sceats Memorial Home for more information

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a team of dedicated staff that work hard to maintain the quality of service users lives. All comments received about the staff were very complimentary. The Registered Manager and Deputy manager have worked at the home for a number of years resulting in continuity for staff and service users. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices.The home has systems in place to ensure that service users are assessed prior to admission to the home and this could be further improved by the home confirming in writing that they can meet the needs of the service user. The home offers service users a variety of activities on an adhoc basis with service users being able to choose how they spend their time each day.

What has improved since the last inspection?

The home has addressed an issue with a hot water unit in a service user`s bedroom by monitoring the temperature to ensure this service user is not at risk. Staff supervision sessions have been improved with a regular programme.

What the care home could do better:

The home needs to ensure that care plans are updated with any changes to service users conditions and that care plans are in place for all service users needs. Some improvements are needed with the medication systems used to ensure safe practices. Improvements have been made to parts of the environment but other parts have not been decorated for some time and the bathrooms are not very inviting. Whilst this does not pose a risk to service users it does not make for a pleasing or pleasant environment to live in. The staff do not have a room to take their breaks in and consideration should be given to providing this facility when the home is looking to increase their communal area for service users. To improve their quality assurance systems the home needs to record their monitoring of the home and devise other ways of obtaining service users views. The management of the home need to observe staff during their work to help with supervision and spend time working with the staff and service users.

CARE HOMES FOR OLDER PEOPLE Sceats Memorial Home 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 13:00 6 & 7 September 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sceats Memorial Home Address 1-3 Kenilworth Avenue Gloucester Glos GL2 0QJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01452 303429 Sceats Memorial Housing Association Limited Mrs Iris Anne Burton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/11/05 Brief Description of the Service: Sceats is a Care Home, which provides personal care to the older person. It is situated in a residential area on the outskirts of Gloucester City. It offers accommodation over two floors in two, extended Victorian houses. Bedrooms are single and have wash hand basins. Communal toilets and bathrooms are near to all bedrooms and main communal rooms. There are two lounges, one dining room and a sunroom on the front of the property. The building is accessible by wheelchair; the first floors are reached by stair lifts, but some bedrooms are not easily accessed unless the individual is confidently mobile and advice would need to be sought from the Registered Manager as to which bedrooms are affected. The home has a copy of their Statement of Purpose on display in the main entrance hall and all service users in the home have a copy of their Service Users Guide. The fee range for this home is £311.85 to £378.75 per week and extras include hairdressing, newspapers and chiropody. This information was given to the inspector prior to the inspection. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection on two days in September 2006. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was available during the second day of the inspection as were other members of the home team. A total of 26 standards were inspected. Several residents were spoken with to ascertain their views on the care and services provided. A number of surveys were left for service users, staff and visitors to the home. Of these, the majority were complimentary about the home. However some comments received said that the management of the home do not help staff out when they are short staffed and the management do not observe staff during their work. Another comment was that the staff to do not have their own room to take their breaks. The comments received from service users during the inspection all indicated they are very happy living at the home. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feed back on the inspection findings were given on completion and were received in a constructive and positive way by the Registered Manager. What the service does well: The home has a team of dedicated staff that work hard to maintain the quality of service users lives. All comments received about the staff were very complimentary. The Registered Manager and Deputy manager have worked at the home for a number of years resulting in continuity for staff and service users. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 6 The home has systems in place to ensure that service users are assessed prior to admission to the home and this could be further improved by the home confirming in writing that they can meet the needs of the service user. The home offers service users a variety of activities on an adhoc basis with service users being able to choose how they spend their time each day. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home’s admission procedure ensures that all service users are admitted on the basis of a full assessment of their needs. Prospective service users and their family/representatives have the opportunity to visit the home and assess it for its suitability prior to the service user moving in. EVIDENCE: From discussions with the Deputy Manager no changes have been made to the Statement of Purpose or Service Users Guide. A copy of the Statement of Purpose is available in the main entrance hall. All service users have signed to say they have received a copy of the homes Service Users Guide. Consideration should be given to the home checking their terms and conditions to meet with the changes to the Care Home Regulations. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 9 The pre admission assessments of two recently admitted service users were examined and both contained information relating to their care needs. On admission both these service users were re assessed and monthly reviews have continued since they were admitted. The Deputy Manager said part of the admission process is for the proposed service user to spend a day at the home prior to moving in so that an assessment of their needs can be undertaken. One service user confirmed that they had spent a day at the home prior to moving in. The Deputy Manager said the home has plans to allocate a staff member to each new service user to help them in settling in. An admission checklist is completed for each new service user. There was no evidence that the home confirms in writing to prospective service users that the home can meet their needs. Intermediate care is not provided in this home. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home has a clear care planning system in place but lack of updating is not providing staff with the adequate information needed to satisfactorily meet service users needs. Some of the systems used for managing service users medication could potentially place service users at risk. Service users are treated with respect. EVIDENCE: The care of three service users was examined in detail. All three had an ongoing assessment of need that had been reviewed monthly. All three had care plans devised from their assessment completed on admission and evidence was seen of reviews. Daily records are maintained as well as a list of health professional visits. One service user requires their care plan to be up Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 11 dated, as it does not mention their mental health condition and how the home manages it. A service user had signed to say they agree with their care plans. One service user had a care plan in place on how to manage a prescribed medication. A care plan was also seen for one service user’s social needs. Moving and handling assessments were seen for all three-service users, however one assessment needs updating, as this service user is now unable to walk. The Deputy Manager is in the process of completing falls risk assessments for all service users. During the inspection a Community Nurse was visiting a service user and later they had a review of their placement. The systems used to manage service users medication was examined. Records were seen of medication received, administered and returned to the pharmacy. The home uses printed Medication Administration Records (MAR) sheets from the pharmacy, however a number of hand written entries were seen, some were not signed by the person writing the entry and others were not signed by a second person checking the entry. Consideration must be given to ensuring that all handwritten entries are signed by the person writing it then checked by and signed by a second person. Dates of opening were seen but not on all medication as indicated by the Deputy Manager. A member of staff was observed administering the lunchtime medication, however the staff member was dispensing the medication into their hand before putting it into a plastic container. This practice is not safe as it is an infection control risk and the member of staff could absorb some of the medication. The home uses a trolley to transport medication around the home but due to the layout of the home it is not possible for the trolley to be taken to some areas. The home must risk assess the system they use to transport the medication to these areas to ensure the medication is stored securely at all times. Consideration should be given to purchasing a lockable facility that is easy to carry. Two service users are receiving controlled medication; ongoing records for this are maintained in a register, however the running total does not take into account the stock controlled medication therefore the homes records are not accurate and auditing of these medications would be incorrect. Service users are able to self medicate and the home has a policy for this. This was not examined in detail at this inspection. The MAR sheets were examined and it was noticed that one service user is receiving a weekly medication but for the last two weeks this had not been signed for, therefore the home would not know if this was given or not. Consideration should be given to auditing of the MAR sheets to check they are being completed correctly. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 12 Service users confirmed that their privacy and dignity are maintained. Staff were observed treating service users with respect and the majority of service users spoken with said they like to be addressed by their first name. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users are able to make choices about their lifestyle to suit their preferences and maintain contact with family and friends as they wish. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The home does not have a structured activities programme as staff undertake activities on a adhoc basis. A number of board games were taking place during the inspection. From discussion with service users they did not feel that it was an issue that they do not have a programme, as they like to be able to make their own choices. Two members of staff have been trained to undertake activities that encourage service users with their mobility and to help prevent falls. The chef has been assigned one half day a week to undertake crafts with service users and the centre pieces on display on each table in the dining room are made by the service users. One service user Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 14 helps the chef in the greenhouse and other service users also made the hanging baskets. One service user said she goes out to church every Sunday. From discussions with service users they are able to chose how they spend their time each day and that visiting to the home is open. A comment card received from a visitor to the home following the inspection said that they arrived late morning to see their relative but the home was very accommodating by providing them with lunch. Another comment that was mentioned on a number of visitor comment cards was that the staff are very friendly and helpful and one said very welcoming. A number of visitors were at the home during the inspection. Several service users rooms were seen and these were all personalised to the service user and had their own furniture and items around the rooms. Several had their own telephone. In the main entrance the home has a notice board that has on display information that could be useful to service users and their visitors. The home operates on a four weekly menu rotation that was devised prior to the Chef starting at the home. She has devised a new winter menu. At service users meetings they are asked for their input into the menu and as the chef serves the food service users are also able to go to her direct with any comments. An alternative is always offered at lunchtime as the home has three vegetarians and alternatives are offered at teatime. The chef said they are able to cater for service users who require a therapeutic diet. Lunchtime was observed and found to be a very social event with service users able to have alcohol as their medical condition allows. The Manager working in the home on that day has lunch with the service users. Service users are offered assistance discreetly, however it was noticed that on this day one member of staff was assisting a service user to eat their meal whilst stood up. The Deputy Manager said this does not normally happen. Baskets of fruit are now left on the table for service users to help themselves. Service users all complimented the food provided by the home and said they are able to chose where they have their meals. The kitchen was inspected but not in detail and the chef provided evidence that health and safety checks are undertaken. Records of food were also seen. The Chef has completed the advanced food course. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has a complaints system in place with evidence that the views of service users are listened to and acted upon. Staff have knowledge and understanding of adult protection issues to provide a safe environment to protect service users from abuse. EVIDENCE: The home has received two complaints. The appropriate records were maintained as well as the action taken to address the issues in the complaint. The home has their Statement of Purpose on display with their complaints procedure in it. Consideration should be given to displaying a copy of this procedure separately from the Statement of Purpose. All service users have signed as evidence that they have a copy of the homes Service Users Guide. Service Users and staff all said they could approach the Registered Manager or Deputy Manager if they had any concerns. One comment card received said the home provides a safe, calm and caring place to live. Adult protection training has been provided for all care staff, and this was confirmed by staff and their training records. The home also has a whistle Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 16 blowing and abuse policy. Staff were able to say what action they would take if an allegation was made. Consideration should be given for the management of the home to attend training for local procedures. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. There have been some changes to the décor in parts of the home in the last 12 months but other areas have had no changes. Although this does not pose a risk to service users it does not create a pleasing and pleasant environment to live in. EVIDENCE: A tour of the environment took place with a number of service users rooms seen. A small number of maintenance issues were seen to include a broken window in toilet 102 and toilet frames in a number of toilets were rusty. This was fed back to the Registered Manager during the second day of the inspection. The treatment room has been redecorated since the last inspection as well as some corridors. It was noticed that a number of areas in the home are looking tired and this is now more evident with other areas being decorated. At the last inspection it was noticed that the bathrooms look very Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 18 institutional and this is still the same at this inspection. Whilst this does not pose a risk to service users it does not create a pleasing and pleasant environment to live in. Since the last inspection one communal sitting room has been turned into an office without consultation with the Commission, however plans are in place to provide additional communal space to address this. Also the staff do not have their own room for breaks and consideration should be given to providing this when the plans are drawn up to increase service users communal area. No odours were found during this inspection and service users spoken with said they were happy with the cleanliness of the home. Staff were seen wearing protective clothing when required. A number of staff have completed a course in infection control. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. The standard of vetting and recruitment practices needs improving, as not all the appropriate checks are being carried out, potentially leaving service users at risk. EVIDENCE: Duty rotas were seen during the inspection for care and ancillary staff. The homes management team feel confident that the needs of the service users are being met on their numbers of staff. One service user was having a review of their care during the inspection by Community and Adult Care Directorate. A member of the management team is available during office hours each day. Staff spoken with had a good understanding of the needs of the three service users whose care was examined in detail. Service users and comments received from the comment cards were very complimentary about the staff. Comments were that they are very friendly, helpful and welcoming to visitors to the home. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 20 Staff spoken with all said they enjoy working at the home and they have a good staff group. Several members of staff have been working at the home for a number of years to include the Registered Manager and Deputy. Six care staff have completed NVQ 2 and two other staff are undertaking the course at the present time. The home has not had to use agency staff recently. The home has only had one new member of staff since the last inspection and their personnel file was examined. Only one written reference was found and this was from their last employer and the home was trying to obtain another one. A full employment history was not available as the homes application form only requests the last ten years. A POVA/CRB (Criminal Records Disclosure) had been applied for but the member of staff started working at the home prior to their POVA check being returned. The Deputy Manager thought that staff could start at the home without the POVA check as long as they are supervised. The home must improve on their recruitment procedure to ensure service users are not being put at risk. This member of staff is going to work nights however they started in July but to date have not undertaken induction training; and as their CRB disclosure has not been returned they must be supervised. The home uses an outside trainer for their induction training and the course is devised along the lines of the NVQ 2 standards. A number of staff files were sampled as evidence that training is taking place. Consideration should be given to devising a matrix for easy recognition of what training has been undertaken and when it is next due. The Deputy Manager said that all mandatory training has been provided for the majority of staff and this is an ongoing process. Food and hygiene training is to be provided for all staff that serve food. Staff confirmed that training is provided and some staff are undertaking a course in dementia. The home needs to ensure staff have the training needed to assist them with their job roles. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Service users’ benefit from the continuity of a long serving Registered Manager who has a supportive, open approach to running the home, which benefits the service users, staff and relatives. The systems for service user consultation in this home need improving as there is little evidence that service user views are sought or acted upon. The home ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 22 EVIDENCE: There have been no changes to the management structure of the home, with both the Registered and Deputy Manager having worked at the home for a number of years. The Registered Manager is aware of the importance of keeping herself updated and she helped to train the staff in adult protection issues. Service users, staff and visitors to the home all said they could approach the Registered Manager if they had any concerns. A comment card received following the inspection said the Registered Manager was very helpful and accommodating during their visit to the home. However comments received from surveys’ said that the management of the home do not help the staff out when they are short staffed and they are not observed during their work. This must be addressed. The home has service users meetings at least twice a year and minutes of these were seen. The last time questionnaires were sent to service users was July 2005. The home should consider doing this at least yearly and send them out to relatives and other visitors to the home. The home should also collate the results and display them in the home. Regulation 26 visits are taking place and a copy is sent to the Commission. Monitoring systems used were discussed as these are taking place but records are not being maintained. Accident records are audited. Evidence was seen that policies and procedures are reviewed yearly but the home should ensure these are reviewed in line with any new legislation. The home is able to store service users monies securely and the appropriate records are maintained and receipts kept. The home has devised a programme for staff supervision and records were seen of sessions undertaken. The Deputy Manager said they are struggling to find topics to discuss at supervision sessions and advice was given on how to address this. Staff confirmed that they are receiving supervision sessions. Records of maintenance of equipment and regular checks were seen. During the inspection the home was having their electrical systems checked. Several checks on equipment were overdue to include central heating system, Legionella and baths. The Deputy Manager said these would be addressed as soon as possible. Monthly water checks are taking place and this includes the water heater identified at the last inspection as being too hot. Window restrictors were not inspected. The home has completed their fire risk assessment and consideration should be given to ensuring they meet the new fire regulations that are due to be introduced soon. Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d) Requirement The registered person must confirm in writing to proposed service users that having regard to their assessment the home is suitable for the purpose of meeting their needs. The registered person must ensure that any change to a service user’s condition is documented in their care plan. The registered person must ensure that a risk assessment is carried out to determine if the procedure they use to transport medication to rooms not accessible by the trolley, is safe. The registered person must ensure that handwritten entries on Medication Administration Records are signed by the person writing them, and by a second person to check the entry to reduce any risks to service users. The registered person must ensure that accurate records are maintained of all controlled medication. The registered person must DS0000016573.V311060.R01.S.doc Timescale for action 18/11/06 2. OP7 15 18/11/06 3. OP9 13(2) 18/11/06 4. OP9 13(2) 18/11/06 5. OP9 13(2) 18/11/06 6. OP19 23(2)(b & 30/11/06 Page 25 Sceats Memorial Home Version 5.2 c) 7. OP29 7,9,19.Sc h 2 (5) ensure that the minor maintenance issues are addressed as detailed in this standard. The registered person is required to ensure that two written references are obtained when employing new staff, before they commence employment. The registered person must obtain the following pre employment checks: 1) A full employment history, together with a satisfactory written explanation of any gaps in employment. 2) Criminal Records Disclosure (including where applicable a POVA check). The registered person must ensure that all new staff receive structured induction training. The registered person must ensure that for the duration of the new workers induction training: i) a member of staff (“the staff member”) is appropriately qualified and experienced, is appointed to supervise the new worker; ii) as far as is practicable, the staff member is on duty at the same time as the new worker; and iii) the new worker does not escort any service user away from the care home premises unless accompanied by the staff member. Where a registered person permits a new worker to start work as defined in this regulation the registered person shallDS0000016573.V311060.R01.S.doc 30/11/06 8. OP29 19 & Sch 2 30/11/06 9. 10. OP30 OP30 18 1(c)(i) 18(2) 30/10/06 30/10/06 11. OP30 19(11) 30/10/06 Sceats Memorial Home Version 5.2 Page 26 a) appoint a member of staff (“the staff member”) who is appropriately qualified and experienced, to supervise the new worker pending receipt of, and satisfying himself with regard to, the outstanding information in relation to a criminal record certificate. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP2 OP9 OP9 OP9 OP12 Good Practice Recommendations The home should ensure their terms and conditions are in line with the new Care Home Regulations. The home should purchase a lockable box to transport medication to the areas in the home that is not accessible to the trolley. The staff should not put medication directly into their hands as this is an infection control risk and staff could absorb the medication. The home should audit the Medication Administration Records as part of their quality assurance systems. Consider transport arrangements, which may help service users with limited mobility to enjoy such things as shopping and trips out. Continue with redecoration to the home including the Appliances room. Make bathrooms less institutional in appearance and plan to replace the strip light in bedroom 4. 6. OP19 Sceats Memorial Home DS0000016573.V311060.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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